Original research Pan American Journal

of Public Health

Factors associated with chronic kidney disease of

non-traditional causes among children in Guatemala
Alejandro Cerón1, Brooke M. Ramay2, Luis Pablo Méndez-Alburez3, and Randall Lou-Meda4

Suggested citation Cerón A, Ramay BM, Méndez-Alburez LP, Lou-Meda R. Factors associated with chronic kidney disease of non-traditional
causes among children in Guatemala. Rev Panam Salud Publica. 2021;45:e24. https://doi.org/10.26633/RPSP.2021.24

ABSTRACT Objective. To identify factors associated with chronic kidney disease of non-traditional causes among children
in Guatemala.
Methods. A cross-sectional survey was conducted. The study population was all pediatric patients with stage
5 chronic kidney disease active in FUNDANIER’s pediatric nephrology unit (N = 156). Simple random sampling
led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and house-
hold characteristics, access and utilization of health care, and place of residence when the disease began.
Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were
collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate
analysis.
Results. The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household charac-
teristics were mother’s education level up to primary school (OR 2.2727) and living in an urban setting when
symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale
agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence
intervals show that the sample was not big enough to capture statistically significant associations between
variables.
Conclusions. Study findings suggest that factors associated with chronic kidney disease of non-traditional
causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and
mother’s level of education. Future research in children could use case-control designs or population-based
studies in agricultural communities. Public health interventions that involve kidney function screening among
children are recommended.

Keywords Renal insufficiency, chronic; kidney failure, chronic; risk factors; child health; epidemiology; Guatemala.

In the past four decades, chronic kidney disease (CKD) has or environmental pollution are on the rise and affect primar-
increased worldwide so extensively that some consider it a pan- ily male agricultural workers between their 20s and 50s (2, 3).
demic (1). CKD can lead to renal failure that is treatable only There is documentation that these less common causes may
by peritoneal dialysis, hemodialysis, or renal transplantation, affect women, children, and men who do not directly work
all of which come with important financial burdens and social in agriculture (3, 4), a trend documented mainly in Central
impacts. The worldwide rise in CKD cases is attributable to America and Sri Lanka, with additional reports from Egypt,
the increased number of people living with diabetes and high India, Mexico, and Sudan (1, 2, 4). Although the disease has
blood pressure. Other, less common causes such as infection, been given different names, such as CKD of unknown cause,
injury, and exposure to toxins from drugs, herbal supplements, Central American nephropathy, Sri Lankan nephropathy,

1
University of Denver, Denver, CO, United States of America *  Alejandro
  3
Universidad Maya Kaqchikel, Chimaltenango, Guatemala
Cerón, Alejandro.CeronValdes@du.edu 4
Fundación para el Niño Enfermo Renal—FUNDANIER, Guatemala City,
2
Universidad del Valle de Guatemala, Guatemala City, Guatemala Guatemala

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original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization
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Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.24 1

Original research Cerón et al. • Chronic kidney disease of non-traditional causes
Uddanam nephropathy (India), chronic interstitial nephritis
in agricultural communities, and El Salvador nephropathy
(1–5), the Pan American Health Organization (PAHO) has rec-
ommended to consider them all as possibly the same disease,
and to call it CKD of non-traditional causes (CKDnT) (3). In
Central America, CKDnT is a public health priority because
it has reached epidemic proportions (3). The cause of CKDnT
remains unknown, although available evidence shows that
its main driver is occupational heat stress (5). Possible causes
under study include heat exposure, exposure to pesticides,
consumption of water containing heavy metals, overconsump-
tion of anti-inflammatory medications, tobacco use, inadequate
hydration, infections (leptospirosis, hantavirus, malaria), low
birthweight, and genetic predisposition (3, 4). Most research-
ers attribute CKDnT to multifactorial causes, with an interplay
of repeated heat exposure and poor hydration working in syn-
ergy with exposure to toxins and infectious agents to damage
the kidneys (1–3). In adults, signs and symptoms may include
fatigue, fainting, cramps, joint pain, polyuria, dysuria, foamy
urine, hypotension, normal fundoscopy, vascular irregularities
of lower limbs, altered neurological reflexes, and hearing loss.
Characteristic laboratory findings are absence of severe protein-
uria and markers of tubular damage. Renal histology shows
evidence of chronic tubulointerstitial nephritis with glomerulo-
sclerosis and mild chronic vascular changes (1–5).
Although the number of studies on CKDnT has been
increasing in recent years, the information related to pediatric
population is scarce. At the largest pediatric nephrology center
in Guatemala, 43% of CKD cases were attributed to undeter-
mined causes, the majority of which patients came from regions
with documented cases of CKDnT in adults (6). In El Salvador,
a descriptive epidemiologic study (7) among children under
18  years in three agricultural regions with known high prev-
alence of CKDnT identified a CKD prevalence of 3.9%. In
Nicaragua, a cross-sectional study (8) of teenagers from four
schools compared regions hypothesized to have different levels
of environmental exposures leading to kidney injury at a young
age. The four schools were located in communities that differed
in overall CKD mortality, types of predominant agricultural
activity, and altitude. Levels of kidney injury were significantly
higher among participants who came from the school located
in a community where adults primarily work in sugar cane
plantations. No additional studies focusing on risk factors of
CKDnT have been identified in the literature (1–5).
In Guatemala, the estimated prevalence and incidence of CKD
among children are 4.9 and 4.6 per million age-related popula-
tion, respectively (6). The country’s capacity to comprehensively
treat children with CKD through its public health care system
was solidified in 2003, when parents of children with CKD cre-
ated the Fundación para el Niño Enfermo Renal (Foundation
for Children with Kidney Disease, FUNDANIER) (9, 10). Since
its inception, FUNDANIER has supported a pediatric nephrol-
ogy unit at one of the country’s tertiary-level referral hospitals
in Guatemala City, and it has helped found the country’s only
pediatric kidney replacement therapy program. FUNDANIER’s
pediatric nephrology unit receives patients from all over the
country, accepts walk-ins and referrals by any health care pro-
vider, does not charge patients for any medical fees for services
or donated products, and sometimes covers lodging costs for
families in need. Given its location in Guatemala City, patients
from rural areas may face geographic and associated financial
2 Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.24
barriers to access. While pediatricians and general practitioners
see common renal problems, it can be assumed that the great
majority of pediatric patients with advanced CKD are eventu-
ally seen in FUNDANIER’s pediatric nephrology unit.
The goal of this study was to identify factors associated
with CKDnT among children in Guatemala at the individual,
household, and community levels, with a special emphasis on
elucidating the role of access to health care services and envi-
ronmental factors suggested by previous research (6).
MATERIALS AND METHODS
Research design
A cross-sectional survey was designed to determine factors
associated with CKDnT. Independent variables were defined
using a conceptual model based on three complementary
sources. First, causal models derived from reviews of literature
on CKDnT, which emphasize certain environmental exposures
related to temperature, altitude, and exposure to agrochemi-
cals (1–4). Second, the behavioral model of health services use,
which categorizes predisposing, enabling, and need factors
associated with access and utilization of health care services
(11,  12). Third, published sources that describe factors which
affect access to health care in Guatemala (13). Independent
variables identified through these sources were organized in
a conceptual framework with factors at the individual, house-
hold, and municipal levels.
Population and sample
The study population was the total of pediatric patients
with stage 5 CKD who were active at the end of July 2015 in
the clinical database of FUNDANIER’s pediatric nephrology
unit (N = 156). The population included patients identified in
the FUNDANIER database classified as stage 5 CKD, using
the guidelines of the National Kidney Foundation’s Kid-
ney Disease Outcome Quality Initiative (KDOQI), if they
showed  an estimated glomerular filtration rate (eGFR) of
<15 mL/min/1.73m2, or were on renal replacement therapy
(14), with a documented etiology for CKD, and who were
accompanied by a parent or guardian. A sample size of 90 was
estimated through simple random sampling, with an alpha
of 0.05 and a proportion of CKDnT cases in the population of
84% based on FUNDANIER’s database. A decision was made
to aim at recruiting 105 participants, with the goal to account
for incomplete information in patient medical records.
Data collection
Participants were recruited after their appointments in
FUNDANIER’s pediatric nephrology unit. Interviews were
conducted between September 2015 and April 2016, in Span-
ish, in a private space, and consisted of a questionnaire that
took between 20 and 30 minutes to administer by author
LPMA. The questionnaire had been previously validated in five
FUNDANIER patients with stage 4 CKD for comprehension,
internal consistency, and duration. The questionnaire (available
from authors upon request) consisted of 70 questions, address-
ing individual (e.g., age, sex, ethnicity, level of education) and
household (e.g., income, parental level of education, primary
Cerón et al. • Chronic kidney disease of non-traditional causes Original research
language) characteristics, access and utilization of health care
(e.g., time to diagnosis, access to the clinic, home care), treat-
ment adherence (for a separate analysis reported elsewhere)
(15), and place of residence when the disease began. Addition-
ally, data collected from medical records included CKD etiology
(used for classifying the dependent variable), and KDOQI clas-
sification (used to confirm inclusion criteria).
Information about place of residence when symptoms began
was used as a proxy for investigating the environmental and
health care access factors in the conceptual model. Municipality-
level data were collected on average temperature, average
humidity, average evapotranspiration (16), total population,
percentage of people dedicated to agriculture (17), number of
health care facilities (18), and predominant use of land (19). Pre-
dominant use of land classifies municipalities into six agrarian
zones: zone 1 corresponds to intensive small-scale agriculture
linked to distribution systems; zone 2 refers to small-scale agri-
culture within regions dedicated to large-scale exports; zone 3
describes marginal use of agriculture combined with seasonal
work in other industries; zone 4 refers to small-scale industries
combined with multiple informal activities; zone 5 corresponds
to growing small-scale agriculture restricted by large-scale
industries; and zone 0 refers to metropolitan urban areas. As
a general pattern (19), municipalities in agrarian zone 1 use
intensive agriculture to compete in local and regional mar-
kets, while municipalities in agrarian zone 3 use agriculture
for self-consumption. Municipalities in agrarian zone 2 have
large plantations dedicated to export crops and surrounding
communities dedicated to agriculture for self-consumption.
Small-scale agricultural workers from zones 1 and 3 are often
seasonal workers in plantations located in zone 2.
Data analysis
The dependent variable was classified as CKDnT if the
medical records showed that etiological investigation had
classified the final diagnosis as “CKD of undetermined cause,”
which FUNDANIER has been classifying for several years as
those patients with renal ultrasound without hydronephrosis,
cystography free of reflux, and no history suggesting nephritic
or nephrotic syndrome. No data about biopsy diagnosis were
collected. This definition is compatible with the PAHO defi-
nition for suspect case of CKDnT, defined as a person under
60 years of age with one abnormal result that meets the Kidney
Disease Improving Global Outcomes (KDIGO) CKD criteria,
and who has no history of type 1 diabetes, no history of hyper-
tensive disease, and no history of other known causes of CKD
(20). A database (available from authors upon request) was
built with the questionnaire results and the additional munic-
ipality-level variables. Statistical analysis used STATA® 12.1
(StataCorp LP, College Station, Texas, United States of Amer-
ica). For each variable, descriptive statistics were estimated.
Logistic regression was used for bivariate and multivariate
analysis, using a 0.05 threshold to assess if associations were
statistically significant.
Research ethics
Ethics approval was obtained from the Institutional Review
Board at the University of Denver, and the ad-hoc research eth-
ics committee at FUNDANIER. Written informed consent was
Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.24 3
obtained from parents or guardians accompanying minors who
participated in this study, and written informed assent was
obtained from minors between the ages of 7 and 17 years old.
Consent, assent, and the interview were carried out in a private
space. To guarantee participants’ anonymity, personal identi-
fiers, including names and clinical record identification, were
not collected.
RESULTS
We approached every patient who arrived for clinic appoint-
ments until we recruited 105 participants. Five patients were
excluded because they did not have a completed etiolog-
ical investigation in their medical records. The remaining
100 patients were included in the study, of which 76 (76%) were
classified as CKD of undetermined cause, and 24 (24%) had
an identified etiology as follows: 14 (14%) congenital anom-
alies of the kidney and urinary tract—CAKUT (6 neurogenic
bladder, 7  vesicoureteral reflux, 1 prune belly syndrome); 7
(7%) glomerulopathies (6 idiopathic glomerulopathies, 1 lupus
nephritis); 1  (1%) tubulopathy; 1 (1%) hereditary nephritis
(branchio-oto-renal syndrome); and 1 (1%) nephrolithiasis. All
patients were receiving renal replacement therapy, including 40
(40%) on peritoneal dialysis, 25 (25%) on hemodialysis, while 35
(35%) patients had a transplant.
Fifty-four participants were female. Median age was 14 years,
with 12 (12%) participants aged 6–9 years, 42 (42%) aged
10–14, and 46 (46%) aged 15–18 (mean age 13.66, minimum
6, maximum 18, standard deviation 3.09). Thirty-nine (39%)
self-identified as indigenous, all participants (100%) spoke
Spanish as their first language, although five (5%) also spoke an
indigenous language. Sixty-six (66%) patients had attended up
to primary school, 19 (19%) had attended secondary school, and
5 (5%) had attended high school or vocational school. Fifty-nine
(59%) were attending school regularly.
Table 1 presents the household- and municipality-level
variables most relevant to the analysis and discussion. Moth-
ers were the primary caregiver for 72 (72%) patients, 11 (11%)
had rotating care between relatives, 7 (7%) were taken care
of by another member of the nuclear family, and 10 (10%) by
aunts, grandparents, or neighbors. Eighty-five (85%) mothers
spoke Spanish to the child participant, 10 (10%) spoke com-
bined Spanish and an indigenous language, 1 (1%) spoke an
indigenous language, and 4 (4%) did not respond to this ques-
tion. Twenty-two (22%) participants lived less than 2 hours
from the clinic, 47 (47%) 2–4 hours, 21 (21%) 4–6 hours, and
3 (3%) patients lived more than 6 hours away. Sixty-six (66%)
participants used the public bus system for transport to clinic
appointments, 13 (13%) used their family vehicle, and the rest
(21%) used a combination of bus, taxi, and private vehicle.
Sixty-seven (67%) participants lived in urban areas at the time
of questionnaire administration. Twenty-three (23%) partic-
ipants reported having moved their hometown due to their
illness, to be closer to health care facilities, or to improve
household sanitary conditions.
Municipalities where participants lived when symptoms
started represent 44 out of the country’s 340 municipalities,
distributed in 15 departments (provinces) out of the country’s
22 departments (Figure 1). Average annual rainfall in these
municipalities ranges from 15 to 27.5 inches. Fifty-six (56%) par-
ticipants came from municipalities with 20 inches of average
Original research Cerón et al. • Chronic kidney disease of non-traditional causes

TABLE 1. Selected household- and municipality-level char- municipalities where participants lived in when symptoms
acteristics of research participants, Guatemala, September began. Participants lived in municipalities that fall under four
2015–April 2016 out of the six agrarian zones described in the methods section
(Table 2).
Variables Total %
(n = 100)
Bivariate analysis
Household characteristics
Lives in a city currently 100 100 Table 3 shows the results of the bivariate analysis. The odds
No 33 33 ratios (OR) for all individual-level, most household-level, and
Yes 67 67 most municipal-level characteristics approach 1. Exceptions to
Time to referral (days since first symptoms to 100 100 the category of household characteristics were mother’s educa-
referral to FUNDANIER) tion level up to primary school (OR 2.2727), the type of place of
1 week or less 14 14 residence (rural or urban), when participants’ symptoms began
Between 1 week and 1 month 38 38 (OR 0.4035), currently living in a city (OR 0.3241), and presence
Between 1 and 6 months 23 23 of several caregivers (OR 0.3304). Exceptions in municipal char-
Between 6 months and 1 year 6 6 acteristics are agrarian zone 1 (OR 3.8923) and agrarian zone 2
More than 1 year 19 19 (OR 0.3338). P-values and confidence intervals show that the
Mother’s level of education 100 100 sample was not big enough to capture statistically significant
No formal education 9 9 associations between variables.
Attended up to primary school 53 53
Attended up to secondary school 14 14 Multivariate analysis
Attended up to higher education 20 20
No answer 4 4 Table 4 presents results from the multivariate analysis where
Household monthly income (US$)a 100 100
odds ratios are consistent with reported values from the bivar-
Less than $80 8 8
iate analysis for patients with mothers who have education up
to primary school, living in a city, and agrarian zones 1 and 2.
$80–200 29 29
$201–670 45 45
DISCUSSION
More than $670 11 11
No answer 7 7
Results from this study are insufficient to conclude that any
Municipal characteristics
of the studied factors are associated with increased or decreased
Average temperature (ºC) 100 100
odds of having CKDnT at a statistically significant level. It is,
15–17.5 8 8 however, important to offer an interpretation of non-significant
20 56 56 results, in light of the research question, conceptual model,
22.5–25 20 20 and current knowledge about CKDnT. While factors showing
26–27.5 16 16 narrow confidence intervals point to more precise estimates,
Primary health care facilities (per 100 000 100 100 and factors showing wide confidence intervals point to more
population) potential for random error, point estimates showing a tendency
3 or fewer facilities 40 40 are worth examining further, keeping in mind that this study
3–10 21 21 compared participants who already had stage 5 CKD and is not
10.1–20 25 25 representative of the population as a whole.
20.1–55 14 14 Patients coming from agrarian zone 1 demonstrated an
Percentage of EAP in agriculture (%) 100 100 increased odds of CKDnT while zones 2 and 0 showed reduced
20 or less 52 52 odds of CKDnT. Evidence derived from research carried out
21–40 12 12 in adults shows that working in plantations, similar to those
41–60 25 25 defined in agrarian zone 2, is the main driver of CKDnT. Con-
Over 60 11 11 trary to findings in adult patients, we show decreased odds of
Source: Prepared by the authors from study data. CKDnT in this zone. There is no clear insight into what may
EAP: economically active population
a
Converted at 7.50 quetzals per 1 US dollar, rate for 13 August 2016 (www.banguat.gob.gt) explain cases among children (4, 5). In adults, although some
analyses point to a potential role of agrochemicals (1, 2) or
heavy metals in water sources (3), results have been inconclu-
rainfall. While relative humidity in these municipalities was sive. The role of agricultural work-related heat stress has been
in the range 70%–85%, 94 (94%) participants originated from more thoroughly investigated and shows a clearer association
municipalities with relative humidity of 70%–75%. with CKDnT (4, 5), opening up the question of whether its pres-
From the time when symptoms started, participants reported ence in children may signal that they also have been exposed to
waiting a median of 30 days to be referred to FUNDANIER heat stress in working conditions (5). Contrary to our assump-
(range 0–5 000 days, mean 421 days, standard deviation 92). Pri- tions based on previous research on the topic (6), none of the
mary health care facilities in these municipalities ranged from 2 variables measuring availability and utilization of health care
to 55 per 100 000 population. services showed an association with CKDnT. Similarly, at the
The percentage of economically active population (EAP) municipal level, the majority of environmental factors, such
dedicated to agriculture ranged between 2% and 88% in the as temperature, humidity, and altitude, which are part of

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Cerón et al. • Chronic kidney disease of non-traditional causes Original research

FIGURE 1. Municipalities with chronic kidney disease of traditional (CKD-T) and non-traditional (CKDnT) causes in children,
Guatemala, September 2015–April 2016

Source: Prepared by the authors from study data.

TABLE 2. Municipalities of residence of research participants when symptoms began, by agrarian zone and chronic kidney
disease of non-traditional causes (CKDnT), Guatemala, September 2015–April 2016

Agrarian zone Description CKDnT

(n = 100)
No % Yes %
0 Metropolitan urban areas 4 4 8 8
1 Intensive small-scale agriculture linked to distribution systems 1 1 11 11
2 Small-scale agriculture within regions dedicated to large-scale exports 9 9 22 22
3 Marginal use of agriculture combined with seasonal work in other industries 10 10 35 35
4 Small-scale industries combined with multiple informal activities 0 0 0 0
5 Small-scale agriculture restricted by large-scale industries 0 0 0 0
Totals 24 24 76 76
Source: Prepared by the authors from study data.

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Original research Cerón et al. • Chronic kidney disease of non-traditional causes

TABLE 3. Bivariate analysis of variables associated with TABLE 4. Multivariate analysis of variables associated with
chronic kidney disease of non-traditional causes in children, chronic kidney disease of non-traditional causes in children,
Guatemala, September 2015–April 2016 (n = 100) Guatemala, September 2015–April 2016 (n = 100)

Characteristics Odds ratio p-valueb 95% confidence Characteristics Odds ratio p-valuea 95% confidence
interval interval
Individual characteristics Lives in a city 0.4993 0.314 0.1292–1.9291
Age 1.0281 0.713 0.8870–1.1917 Time to diagnosis 0.9996 0.114 0.9991–1.0001
Female 0.9912 0.985 0.3946–2.4896 Mother studied up to primary school 2.2332 0.129 0.7929–6.2971
Indigenous 0.8395 0.727 0.3140–2.2441 Average temperature 1.1269 0.358 0.8733–1.4540
Attends school 1.3713 0.504 0.5428–3.4645 Primary health care facilities, per 0.9755 0.571 0.8955–1.0628
Household characteristics capita
Agrarian zone 1 3.7015 0.339 0.2525–54.2603
Type of place, current residency 1.0057 0.135 0.9982–1.0131
Agrarian zone 2 0.3263 0.387 0.0258–4.1252
Lives in a city 0.3241 0.059 0.1007–1.0433
Agrarian zone 3 1.7951 0.449 0.3942–8.1751
Changed residency due to disease 1.1138 0.851 0.3621–3.4262
Percentage of EAP in agriculture 1.0193 0.427 0.9723–1.0686
Type of place, residency when sick 0.4035 0.102 0.1360–1.1968
Source: Prepared by the authors from study data.
Mother studied up to primary school 2.2727 0.088 0.8840–5.8431 EAP: economically active population
a
Logistic regression
Mother studied up to secondary school 1.3809 0.563 0.4630–4.1189
Mother studied up to tertiary school 0.7391 0.792 0.0785–6.9549
Monthly income below US$ 80a 0.5469 0.435 0.1203–2.4850
Monthly income below US$ 200a 1.1382 0.791 0.4376–2.9606
that they are usually diagnosed between the third and fifth
Monthly income below US$ 670a 1.0893 0.906 0.2642–4.4909 decades of life, when the disease has already progressed, and
Mother speaks only Spanish 1.1429 0.853 0.2775–4.7068 available data in children (7, 8) show that renal damage starts
Mother is primary caregiver 1.1323 0.811 0.4091–3.1344 early in life in areas with high CKD mortality, it is reasonable to
Several caregivers 0.3304 0.093 0.0909–1.2014 hypothesize that exposure during childhood may find clinical
Time to referral 0.9996 0.127 0.9992–1.0000 expression in early adulthood. This hypothesis should be tested
Time to diagnosis 0.9826 0.495 0.9344–1.0333 in future studies, and kidney function screening in children liv-
Municipal characteristics ing in high-risk areas may lead to early detection and treatment
Average temperature 1.0038 0.957 0.8743–1.1524 of CKD. An important finding is that factors commonly associ-
Relative humidity 0.9975 0.975 0.8541–1.1649 ated with health inequities in Guatemala, like ethnicity, sex, and
Evapotranspiration 0.9992 0.645 0.9960–1.0024 income, did not show an association with CKDnT in this sam-
Percentage of EAP in agriculture 1.0096 0.334 0.9901–1.0295 ple. Although CKD more generally disproportionally affects
Agrarian zone 1.0621 0.790 0.6813–1.6557 people with lower incomes, CKDnT does not seem to be more
Agrarian zone 1 3.8923 0.205 0.4759–31.8367 deeply affected. It should be noted that 89 participants’ house-
Agrarian zone 2 0.3338 0.431 0.2590–1.7799
hold income was below the officially estimated average market
basket of consumer goods and services (known as the canasta
Agrarian zone 3 1.1951 0.707 0.4723–3.0243
básica) (23). Additionally, while CKDnT in adults dispropor-
Agrarian zone 0 0.5882 0.424 0.1604–2.1577
tionally affects males, in this sample sex was not an associated
Agrarian zones 1 and 3 1.8121 0.208 0.7183–4.5715
factor. Participants who had mothers with a lower level of for-
Agrarian zones 1, 2, and 3 1.7000 0.424 0.4634–6.2357
mal education showed increased odds of CKDnT. The mother’s
Health care facilities, per capita 1.0086 0.724 0.9616–1.0580
level of education is commonly found to be a significant risk
Primary health care facilities, per capita 1.0122 0.624 0.9642–1.0626
factor for many health problems, such as immunization rates,
Secondary health care facilities, per capita 0.8632 0.336 0.6396–1.1649 child survival, child nutrition, and health care utilization. It has
Source: Prepared by the authors from study data.
EAP: economically active population most commonly been interpreted as a variable that summa-
a
b
Converted at 7.50 quetzals per 1 US dollar, rate for 13 August 2016 (www.banguat.gob.gt)
Logistic regression
rizes a constellation of social and economic factors at play, like
financial security, access to social support, cultural capital, and
access to information (24–26).

conceptual models of CKDnT, did not show an association in Limitations

this sample. A closer look at people, families, and communi-
ties and their dynamics in relation to agriculture, agricultural
practices, and agricultural products may help get closer to an
explanation. For instance, Krisher et al. found distinct levels
of kidney damage among sugar cane workers depending on
where they seasonally migrate from (21), Ramirez et al. found
that altitude and type of agricultural practices are associated
with higher prevalence of tubular renal damage in adolescents
(8), while Herrera-Ruiz showed that labor flexibilization has
shaped workers’ seasonal migration and agricultural practices
(22). Since available evidence on CKDnT in adults (1–5) shows
Limitations of this study are the known ones for cross-sec-
tional surveys based on self-reporting. In addition, the
municipality-level analysis by definition may insert the eco-
logical fallacy into the analysis. The statistical significance was
affected by the number of research participants and the study
duration, in turn affected by the number of actual pediatric
patients with CKDnT. Finally, the dependent variable, CKDnT,
and the municipal-level variables come from secondary data.
The main strength of this study is that it is the first one to focus
on risk factors of CKDnT in children.

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Cerón et al. • Chronic kidney disease of non-traditional causes Original research
Conclusion
The results from this study suggest that factors associated
with CKDnT among children in Guatemala are agricultural
practices in their municipality of residence, and mother’s
level of education. Other variables derived from the con-
ceptual model at the individual, household, and community
level did not show an association with CKDnT. This study’s
emphasis was on elucidating the role of access to health care
services and environmental factors suggested by previous
research (6).
Future research in children could use case-control designs,
but it may prove more fruitful to design population-based
studies in agricultural communities, focused on early detection
and a life-cycle approach. Conducting similar studies in other
affected countries, or multi-country studies, is needed for test-
ing hypotheses in different contexts. Public health interventions
that involve kidney function screening among children, espe-
cially in high CKD mortality areas, are recommended.
Author contributions. All authors conceived the original idea
and designed the research project. LPMA collected the data.
BMR and AC processed and analyzed the data. All authors
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Factores asociados a la enfermedad renal crónica por causas no

tradicionales en niños en Guatemala
RESUMEN Objetivo. Determinar los factores asociados a la enfermedad renal crónica por causas no tradicionales en
niños en Guatemala.
Métodos. Se realizó una encuesta transversal. La población de estudio fue la totalidad de pacientes pediátri-
cos con enfermedad renal crónica en fase 5 ingresados en la unidad de nefrología pediátrica de Fundanier
(N = 156). Mediante el muestreo aleatorio simple se dispuso de un total de 100 participantes. La recopilación
de datos consistió en un cuestionario que abordaba las características individuales y del hogar, el acceso y el
uso de la atención de salud y el lugar de residencia al inicio de la enfermedad. La etiología de la enfermedad
renal crónica se obtuvo a partir de los expedientes médicos y los datos secundarios se recopilaron a nivel
municipal. Se calcularon las estadísticas descriptivas y se empleó el método de regresión logística para el
análisis bifactorial y multifactorial.
Resultados. La razón de posibilidades (OR) se aproximó a 1 en casi todas las variables. Dos excepciones
destacables en lo relativo a las características domésticas fueron el nivel de escolaridad de la madre hasta la
educación primaria (OR 2,2727) y el lugar de residencia en un entorno urbano en la aparición de los síntomas
(OR 0,4035). Las excepciones con respecto a las características municipales fueron las zonas de agricultura
intensiva a pequeña escala (OR 3,8923) y las zonas de agricultura intensiva a gran escala (OR 0,3338). Los
valores P y los intervalos de confianza indican que la muestra no fue lo suficientemente amplia para recoger
las asociaciones estadísticamente significativas entre variables.
Conclusiones. Los resultados del estudio sugieren que los factores asociados a la enfermedad renal crónica
por causas no tradicionales en niños en Guatemala son las prácticas agrícolas intensivas en el municipio
de residencia y el nivel de escolaridad de la madre. Las futuras investigaciones con niños podrían incluir el
diseño de casos o los estudios poblacionales en comunidades agrícolas. Se recomiendan intervenciones de
salud pública que incorporen el tamizaje de la función renal en niños.

Palabras clave Insuficiencia renal crónica; fallo renal crónico; factores de riesgo; salud del niño; epidemiología; Guatemala.

8 Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.24

Cerón et al. • Chronic kidney disease of non-traditional causes Original research

Fatores associados a doença renal crônica de etiologia não tradicional em

crianças na Guatemala
RESUMO Objetivo. Identificar os fatores associados a doença renal crônica de etiologia não tradicional em crianças na
Guatemala.
Métodos. Foi realizado um estudo transversal em uma população que consistiu de todos os pacientes
pediátricos com doença renal crônica ativa em estágio 5 atendidos na unidade de nefrologia pediátrica da
Fundación para el Niño Enfermo Renal (FUNDANIER) (N = 156). O processo de amostragem aleatória sim-
ples determinou a obtenção de uma amostra com 100 participantes. Um questionário foi usado para a coleta
de dados sobre as características pessoais e familiares dos participantes, acesso à assistência de saúde e
utilização de serviços e local de residência ao início da doença. Informação sobre a etiologia da doença renal
crônica foi obtida dos prontuários médicos. Também foram coletados dados secundários ao nível da local-
idade. Estatísticas descritivas foram estimadas e um modelo de regressão logística foi usado nas análises
bivariada e multivariada.
Resultados. As razões de chance (odds ratio, OR) de quase todas as variáveis se aproximaram de 1. As
exceções nas variáveis relativas às características familiares foram escolaridade da mãe de nível fundamen-
tal (OR 2,2727) e residir em área urbana ao início dos sintomas (OR 0,4035). As exceções nas variáveis ao
nível municipal foram áreas de agricultura intensiva em pequena escala (OR 3,8923) e em grande escala (OR
0,3338). Os valores de p e os intervalos de confiança indicam que o tamanho da amostra não foi grande o
suficiente para detectar associações estatisticamente significativas entre as variáveis.
Conclusões. O estudo demonstrou que práticas agrícolas intensivas na localidade de residência e nível de
escolaridade da mãe são fatores associados a doença renal crônica de etiologia não tradicional em crianças
na Guatemala. Outros estudos em crianças devem ser realizados como estudos de caso-controle ou estudos
populacionais em comunidades agrícolas. Recomendam-se também intervenções de saúde pública com a
avaliação preventiva da função renal em crianças.

Palavras-chave Insuficiência renal crônica; falência renal crônica; fatores de risco; saúde da criança; epidemiologia;
Guatemala.

Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.24 9